Rehabilitation, treatment and orthotic management of stroke

The World Health Organization (WHO) estimates that in 2001 there were more than 20.5 million strokes or cerebral vascular accidents (CVA) worldwide, of which 5.5 million were fatal. Two-thirds of the deaths from strokes occurred in developing countries. Hypertension contributes to more than 12.7 million strokes worldwide.

According to the Centers for Disease Control and Prevention, stroke is the third leading cause of death in the United States, killing 283,000 people in the year 2000. On average, someone in the United States suffers a stroke every 45 seconds. Every 3.1 minutes someone dies of a stroke. It is the leading cause of serious long-term disability in the United States. A stroke survivor has a 20 percent chance of having another stroke within two years.

According to data collected from the American Heart Association, there are between 1 million and 1.5 million stroke deaths per year in China. In some areas of China, it is the leading cause of death. The incidence of stroke in China is four times that of acute myocardial infarction. Sixty-one percent of adult males and 7 percent of adult females in China smoke cigarettes.

In Canada, stroke is the fourth leading cause of death. There are more than 50,000 strokes each year, including 16,000 deaths.

The WHO defines stroke as “rapidly developing clinical signs of focal (or global) disturbance of cerebral function lasting more than 24 hours (unless interrupted by surgery or death) with no apparent cause other than of vascular origin.”

Depending on what kind of CVA and the area of the brain effected, patients will present with a range of sensory, motor, speech, behavioral and cognitive problems and therefore, multidisciplinary treatment and rehabilitation goals are tailored to individual needs.

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Types of stroke and warning signs

There are essentially two kinds of strokes — ischemic and hemorrhagic. Ischemic strokes, which are the majority of strokes, are the result of a disruption of blood flow to a portion of the brain. This usually stems from a blood clot in a blood vessel in the neck or brain, therefore causing cell damage in that area. Hemorrhagic strokes are the result of bleeding into the brain, causing injury to brain tissue.

Dara Jamieson MD and Ralph Sacco MS MD in a paper titled, Treating Stroke: How to Reduce the Damage, noted that the foundation for stroke treatment is the immediate recognition of symptoms followed by emergency care.

“The key for stroke treatment is to receive medical treatment in less than three hours,” wrote Sacco.

In the case of an ischemic stroke, the patient may be a candidate for intravenous clot-busting medications to preserve brain cells, improving short- and long-term outcomes.

Jamieson added that clot-busting drugs do not produce an immediate improvement. It takes about three months to see results.

“It is important to understand that damage from stroke is a continuous process,” she wrote. “The brain damage occurs in a cascade of different events … so several things may occur at different times.”

In a bleeding stroke, the chances of dying are greater and the treatment options are fewer. To clear the blood clots, surgery may be necessary.

The warning signs of a CVA are:

Sudden numbness or weakness of the face, arm or leg, especially on one side of the body

Sudden confusion, trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

Sudden, severe headache with no known cause

Jamieson pointed out that one of the problems with stroke is that there is no accompanying pain; therefore, some people don’t think of it as an emergency situation.

Risk factors

Remarkably, approximately 80 percent of CVAs are due to lifestyle choices. Making changes in these behaviors can reduce or eliminate most of the risk factors. Risk factors are:

Hypertension

Obesity/hyperlipidemia/physical inactivity

Diabetes mellitus

Coronary artery disease/atrial fibrillation

Smoking

Male gender

Age

Heredity

Excessive alcohol

Illegal drug abuse

Treatments and rehabilitation

A comprehensive treatment program implemented by a multidisciplinary team of professionals is crucial in the rehabilitative care of each patient. Team members may include physiatrists, physical and occupational therapists, nurses, speech pathologists, psychologists, orthotists and others. Additionally, medications, surgery and other modalities may be incorporated into the treatment plan.

The goals and treatment plan are usually based on the patient’s cognitive abilities, medical condition, functional ability, patient and family goals, expected functional outcome and prior level of functioning. Generally, goals focus on getting the patient as close as possible to the lifestyle they had prior to the stroke.

“Our main objective is to look at their level of functioning after the stroke and assess what their physical needs are with respect to recovery,” said Michael Lupinacci MD, medical director of the HealthSouth Rehabilitation Hospital of Mechanicsburg in Mechanicsburg, Pa. “Some may be ongoing and some may be complications from an acute illness. We need to stabilize these in the process of rehabilitation.”

Other interventions

Thomas Truelsen MD PhD, of the World Health Organization in Geneva, said different types of treatments are available in Europe, depending on the country and whether it is a rural or urban area. Non-pharmacological intervention includes dietary advice and encouragement of physical activity.

“These interventions could lower blood pressure and decrease the risk of developing diabetes and other cardiovascular diseases,” said Truelsen. “It is also important to encourage patients not to smoke and support smokers who are trying to quit.”

Pharmacological intervention for the management of hypertension can also be a component of stroke treatment.

“The systolic blood pressure should not exceed 140 mm Hg,” said Truelsen. “Persons with several risk factors may need to have their blood pressure lowered even more.”

For patients with diabetes, it is imperative that blood sugar concentrations are well controlled through physical activity and diet and when necessary, through pharmacological intervention.

“Additionally, anti-coagulation therapy may be a choice in patients with atrial fibrillation,” said Truelsen.

For acute treatment, patients with ischemic stroke admitted shortly after the start of onset of symptoms may be candidates for thrombolysis (tissue plasminogen activator, tPA).

“This treatment, however, must be initiated within a maximum of three hours after symptoms’ onset,” Truelsen said.

Unfortunately, only few stroke patients are admitted to a hospital that soon and only a small percentage of those patients get treated.

“It is often only hospitals in the larger urban areas that have the capacity to do thrombolysis,” Truelsen said.

Studies have shown that stroke patients have a better outcome if they are admitted to specialized stroke units where the staff are specially trained to take care of them.

Besides nursing and medical treatment, said Truelsen, rehabilitation is central for this group of patients.

“The highest possible level of independence at discharge is the goal.”

Moira Keating MSc BSc (HONS) RGN a specialist nurse in stroke care, Colchester General Hospital, Colchester, England, said thrombolysis as a treatment for stroke is limited to major hospitals and has to be part of a clinical trial.

“Local district general hospitals of the type in which I work, aim to meet the Royal College of Physicians National Stroke Guidelines in all aspects of care of stroke patients,” said Keating. “We are also working toward government directed National Service Frameworks in terms of care provision and service standards.”

According to Dániel Bereczki MD PhD DHAS professor of neurology, Department of Neurology, University of Debrecen, Debrecen, Hungary, in some of the former Eastern Block countries, thrombolysis is available for those with ischemic stroke. But again, only a small number of patients can get this therapy due to delay from stroke onset to arrival to the hospital.

“Additionally, stroke units have been organized in Hungary and some other former Eastern Block countries,” said Bereczki. “Aspirin is also available and is used in most Central and Eastern European countries.”

For secondary prevention, depending on the cause of the stroke, antiplatelets, anticoagulants or carotid endarterectomy are in practice. Statins and hypertensive drugs are also available.

Bereczki added that in the acute setting, mechanic compression (compression stockings) are used to help prevent deep vein thrombosis. Physiotherapy is started early. In case of total plegia, passive movement is used.

“For those who cannot stand by themselves due to the severity of paresis of the lower extremity, we use a standing machine that supports the patient in a standing position,” said Bereczki. “This practice is started as soon as possible after stroke, initially for ten minutes, increasing to 30 minutes over time. It is repeated several times during the day.”

This treatment not only helps prevent some complications of stroke, like hypostatic pneumonia, said Bereczki, but also speeds up rehabilitation.

“For those with less severe paresis, there is a physiotherapist room available with parallel bars, a room-bicycle and other equipment. To practice hand movements, there are special building elements used to improve skills.”

Keating pointed out that services across England are developing at different rates.

“Nationally, there is an objective to provide the same standard of service and provision of care across England,” she said. “Stroke services in the National Health Service are currently being driven to meet this objective through our government’s National Service Framework in Stroke.”

Botox for treatment of spasticity

Botulinum toxin type A (Botox) has been used for more than a decade to treat spasticity or spastic paralysis following strokes and other conditions. With spasticity, mobility becomes difficult or impossible and voluntary muscles are often disabled. Upon injection around specific muscles, the chemical messages that cause the muscles to contract are temporarily blocked, allowing the muscles to relax. The effects last from three to five months.

As far as an adjunct to orthotic fitting, Lupinacci believes botulinum A can be extraordinarily effective in some patients.

“We can inject Botox into those muscles that are specifically affected by spasticity,” he said. “The damaged nerves are telling the muscles to constantly contract.”

Not only does the patient have weakness, but also stiff muscles that do not behave normally. To circumvent the stiffness, particularly in the calf muscles and upper extremity muscles (which are the most commonly dysfunctional muscles in the stroke patient), botulinum A is injected into those areas so that they become relaxed, allowing for a more appropriate fitting of a brace.

“I think the best time to use Botox is early in the course of recovery when the spasticity just begins to set in,” Lupinacci said. “During this period, spasticity gets in the way of recovery. It may not be going away fast enough so we push it out of the picture until natural recovery releases the spasticity so normal strength can return.”

Lupinacci noted that botulinum A can be repeated every three to four months in those patients with chronic spasticity. But, as with any medical treatment, if it ceases to be effective, it should be discontinued.

“Probably two to three courses of the Botox would be sufficient,” said Lupinacci.

Follow up care and prevention

Bereczki’s stroke unit offers patients follow up initially at one to three months after stroke, then every six months or more frequently if needed. Prescribing drugs for secondary prevention (ticlopidine and clopidogrel) requires follow up every one to two months due to local regulations, he said.

“In our unit, there is an outpatient service organized for the follow up of stroke patients three days per week, three hours a day,” said Bereczki.

Truelsen said the WHO is making strong efforts to reduce tobacco smoking. Guidelines for management of risk factors for stroke have been published, and in the future, the beneficial impact of a healthy diet and physical activity will be a priority.

“Access to, and costs of medical treatment are other important aspects that need to be considered,” said Truelsen.

Stroke treatments and diagnostic tests

Thrombolytic Therapy

The U.S. Food and Drug Administration has approved tissue plasminogen activator (tPA) for the treatment of stroke and heart attack. According to the American Heart Association, if tPA is administered within the first three hours of a stroke, it can reduce permanent disability. It is a thrombolytic agent (clot-busting drug) used in ischemic stroke.

Carotid Endarterectomy

Carotid endarterectomy is a surgical procedure used to prevent strokes. Basically, the procedure involves exposing the artery in the neck via an incision and removing the atherosclerotic plague that is causing the narrowing of the artery, thereby improving blood flow to the brain.

Percutaneous Cerebral Angioplasty

A balloon is placed in the area of the carotid artery that has narrowed as a result of athersclerotic plaque that has built up on the walls of the blood vessel. Narrowing (stenosis) of the vessel can cause a thrombus, impeding blood flow to the brain. The balloon is inflated, dilating the vessel, thereby increasing blood flow to the brain.

Diagnostic Tests

Advances in technology allow physicians to determine which part of the brain is affected by a stroke and determine more specifically what problems may occur. The tests are generally painless and can be done on an outpatient basis. A physician will determine which tests to use on a case-by-case basis:

Carotid phonoangiography

Computerized axial tomography

Digital subtraction angiography

Doppler ultrasound test

Electroencephalogram

Evoked response test

Magnetic resonance imaging

Radionuclide angiography

Typical Presentations

When working with a client who has had a CVA, Mary Miller, CO (c), of Orthotic Dimensions Inc, Mississauga, Ontario, Canada, will first observe gait abnormalities. Some of the abnormalities she looks for are drop foot, which is a lack of dorsiflexion during the swing phase of gait, and equinovarus deformity.

“They may have hip hiking during the swing phase and circumduction of the affected leg to try and clear the leg because of the foot drop.”

Some patients may have a lack of knee and hip stability, as well as an incorrect ankle position during their gait cycle.

“Even if a patient is unable to walk and is in a wheelchair, we still want to maintain range of motion in the ankle joint,” Miller said. “It is important to stabilize their leg and keep the foot in a neutral position while they are sitting.”

Another gait problem that is prevalent in these patients, said Miller, is toe contact at the initial stance phase of gait.

Miller pointed out that often, stroke patients are completely unaware of their affected side, “so their hemiplegic side is almost like a lost limb in space and they tend to ignore it. When you see them walking, their unaffected side is always turned forward. It’s as if their affected side is walking behind them.”

It is a proprioceptive issue, said Miller, and the goal is to emphasize to the patient that if they want to walk, they must use both the right and left sides.

Roy Bowers, CPO, a lecturer at the National Centre for Training and Education in Prosthetics and Orthotics at the University of Strathclyde, Glasgow, Scotland, typically observes in his stroke patients an increase in tone in the plantarflexor and inverter muscles of the foot and ankle.

“We see an equinovarus deformity of the foot and ankle often accompanied by a hyperextension or recurvatum at the knee joint,” said Bowers. “It is normally a spastic drop foot rather than a flaccid drop foot.”

Bowers said the deformity of the knee is secondary to the foot and ankle position.

“The combination of these deformities leads to a fairly typical package of gait abnormalities, including things like reluctance to bear weight on the affected limb, asymmetry of step length and timing, inability to extend the hip at the end of stance phase and difficulty in bringing about flexion of the knee in early swing phase. The latter sometimes leads to circumduction of the limb during swing phase.”

Orthotic Intervention: Lower Extremity

The majority of stroke patients will use some form of ankle foot orthoses (AFO) for stability, safety and efficiency of walking.

According to Lupinacci, two types of AFOs are used with stroke patients: plastic AFOs and double-upright AFOs.

“Both types come in a number of variations,” he said. “Some are adjustable, some are fixed, and others have adjustable components for ankle and dorsiflexion. The type of bracing we use depends on what the patient is exhibiting, and how much muscle strength they have in the ankle, calf and lower leg.”

Lupinacci said that patients who are dragging their foot [drop foot] due to reduced dorsiflexion strength or are unable to lift their leg to swing the foot through because of reduced hip flexion — or a combination of both — may be candidates for an AFO.

Alistair Gibson, CPO, LPO, area manager of Hanger Prosthetics & Orthotics in Winter Park, Fla., said that some stroke patients do display drop foot with or without lateral instability due to weakness in the anterior tibial muscle group.

“They may exhibit weakness in the dorsiflexors so the AFO is there to prevent the foot from dragging on the ground when they walk,” said Gibson. “When a patient has drop foot, their increased energy demands on walking are significant.” Additionally, Gibson said that due to quadricep weakness combined with plantarflexor tone, patients will attempt to stabilize their knee by firing off their hip extensors and going into recurvatum.

“The AFO can be a significant aid in managing and controlling recurvatum of the knee,” he said.

Chad Kettler, a physical therapist at Health South Rehabilitation Center in Wormleysburg, Pa., said he will adjust an AFO, perhaps adding a bit more dorsiflexion to break up extensor synergy patterns. He also uses AFOs for patients who have balance issues.

“For example, we may use a dual channel AFO,” he said. “We’ll open up the front channel to allow them to transition their tibia forward over the talus to promote more normal ankle motion, to break up synergy patterns or as they get more return of their dorsiflexors. We also have people who have severe spasticity of the gastrocnemius and soleus muscles.” For those patients, Kettler incorporates various modalities to get the muscles stretched out. He will start a patient off with a dual channel brace, progress to an air cast, and finally, discontinue bracing.

Kettler said springs may be added to an orthosis for dorsiflexion assist if they are not getting any return of the anterior tibialis musculature.

According to Miller, the goals when prescribing an AFO should be retaining range of motion, promoting a better sense of support during weight bearing, encouraging proper gait mechanics and safety and stability issues. The design of the AFO, she said, varies between several types.

The AFO, she explained, can be flexible, semiflexible, rigid or hinge.

“The choice of AFO is determined by the physical assessment of the patient,” said Miller. “If there is clonus present, it must be addressed by perhaps adding some sort of internal strapping that will prevent the foot from popping out of the device.”

To improve the biomechanical correction of the deformity, Miller will put a footplate on the base of a polypropylene AFO.

“I put it underneath the toes,” she said. “This will prevent the toes from curling.”

Additionally, some of the prefabricated AFOs are cut behind the metatarsal heads forming a ridgeline that can cause a pressure area or areas on someone with drop foot, Miller added.

A flexible design would be more appropriate for flaccid foot drop because it is lightweight and all it is basically doing is preventing the plantarflexion deformity of the foot, Miller said. A rigid design will help with plantarflexion spasticity and influence knee and hip stability.

“As far as the conventional design, I rarely use it,” said Miller. “It doesn’t have a lot of contact area so it does not optimally control foot position. There are instances where we have to use it, such as when swelling or hypersensitivity of the skin is evident.”

It can be used, however, as an initial training device in a post-CVA patient because it does not make contact with the skin. “But it is not the definitive device.”

“I have never used a knee ankle foot orthoses (KAFO) on a CVA patient. It is heavy and a stroke patient usually does not have the strength to lift it.”

Bowers also favors the AFOs over the KAFOs. In his experience, he can often control the problem at the knee by correctly addressing the problem at the foot and ankle.

“If we normalize the situation at the foot and ankle with an AFO, then we have a beneficial effect at the knee and hip joint,” he said. “The hip joint typically remains in a rather flexed position throughout stance phase and the patient has difficulty extending his or her hip. So our favored approach is to get an AFO in which the tibia is held inclined forward at some angle to the vertical.”

Bowers finds that this helps manage the problem of knee hyperextension. It also encourages a good second rocker so that they roll over the foot nicely in stance phase. Moreover, it helps with knee flexion and hip extension in the later parts of stance and early swing.

“Whether we use joints or not is another issue,” said Bowers. “I am not overly enthusiastic about the use of ankle joints in these orthoses, particularly in patients who have significant increase in tone. I don’t like to use ankle joints that will allow dorsiflexion in patients with high tone.”

Bowers’ starting position is to try the patient with a solid AFO, which has equinus and varus control in it and is inclined forward to an angle that has to be determined on an individual basis.

“Some people favor ankle joints and some don’t. If you look at the orthotics practice globally, I think there is a fair amount of inappropriate prescriptions for stroke patients. For example, in the literature there are reports of posterior leaf spring or shoe horn type orthoses being used on patients with increased tone. In general, I don’t think this is a proper prescription because it is typically not robust enough to prevent spastic plantarflexion and is not designed to control the varus or supination component of the deformity or the supination part of the deformity of the foot and ankle.”

Orthotic Intervention: Upper Extremity

The majority of orthotic prescriptions for upper extremity stroke patients are for the wrist, hand or both.

“I am referring to static splinting which has no moveable parts,” she said. “They are used to preserve the functional position of the hand and wrist, keeping it in a neutral position.”

After a stroke, Martinelli said some patients have no muscle tone or high muscle tone. Depending on what type of tone the patient presents with determines the kind of orthotic that is prescribed. Every patient who has a stroke does not get a splint or orthoses.

“If they have return in the arm or hand, you don’t want to splint it because it will decrease the function,” she said.

Lupinacci added that the return from stroke is variable. People who have had a mild stroke may get excellent return. Certainly, the hand and upper extremity is more affected than the leg.

“Sometimes the return can be rather dramatic,” said Lupinacci. “So the degree of weakness they started with doesn’t necessarily mean that they’re going to have more impairment.”

Lupinacci said generally, younger people have much more rigorous return than older people, yet it is hard to prognosticate who will get return.

For patients with low tone, one of the hand splints Martinelli uses is a resting pan splint. It preserves the space between the thumb and index finger, minimizes contractures, and helps to prevent injury due to lack of sensation. The splint puts the thumb directly underneath the index finger, fingers are positioned straight out and the wrist is maintained at 15 degrees to 30 degrees of extension.

Martinelli said spasticity is more of a challenge. Splints are used to prevent contractures by preserving the palmer arch. Serial casting and pharmaceutical intervention are frequently implemented as well.

Sometimes, a hand cone can be used to prevent contractures.

Both Miller and Bowers see stroke patients who have a subluxation of the shoulder joint.

“The weight of the arm and lack of muscle control in the shoulder can cause the shoulder joint to sublux,” said Bowers.

Miller said a sling is often used to hold the joint and assist in long-term stability.

As with any orthoses, follow-up care is necessary.

“We see all CVA patients for adjustments in their orthoses,” said Miller. “Because CVA patients can change, you want to make sure you have allowed the initial time for progression. It is important that you work with them as they change in their immediate post CVA condition. As the client changes, their needs — and therefore their goals — will change.”

Assessing Patients

Miller also said that patients must be assessed as individuals. If it is an older person, do they have the proper care at home? Do they have someone to assist them in ambulating, standing and donning and doffing the device? If it is a younger person, Miller will look at their goals and lifestyle and design a protocol that is appropriate.

Bowers added that CVA patients are undergoing some form of physiotherapy program while they are using the orthoses.

“From an orthotic point of view, we review them at about one month after delivery or sooner if they are experiencing any problems.”

Thereafter, Bowers would see them about every three months. That will get longer with the passage of time. If there is a need to change the prescription or realign the existing orthoses, he will do that.

“What I mean by changing the alignment — depending on what we observe in a visual gait analysis — is changing the angle of the inclination of the tibia by the addition or removal of some wedges underneath the heel of the orthoses.”

Resistance to Orthoses

From a psychological perspective, some patients are hesitant or simply refuse to wear orthoses. Lupinacci said they may view them as a sign of their disability. For patients who struggle with this issue, Lupinacci explains to them that it may indeed be a temporary measure to improve their walking, reduce falling and decrease energy requirements.

“Sometimes a patient will graduate themselves from a brace believing they’re moving forward when that is clearly not the case,” said Lupinacci. “They wind up having long-term problems with their knees, hips and back. Anytime there is a biomechanical shift to an abnormal biomechanics of a lower limb, the forces are abnormally transmitted upstream. Orthoses are a long-term preventative measure to save the bones, joints and spine. ”

Miller also experiences resistance in some of her stroke patients to wearing orthotics.

“Most people who have had a stroke want to be the way they were prior to their stroke. They want to walk the same and appear normal. Often, there is some denial about their disability. An AFO or any orthopedic device is a reminder of their disability. As orthotists, we cannot make a device invisible. They think they can get the AFO, learn to walk, then throw the device away. It is important to educate the patient as to why they are wearing the AFO throughout the treatment process.”

Bowers said he doesn’t see much resistance in stroke patients to wearing an orthoses.

“Sometimes, if they have had a bad experience from another center, such as a poorly fitting device or difficulty wearing a device with their normal footwear, then they may not be too enthusiastic. But new patients fairly quickly appreciate the benefits of a well-fitted orthosis. We can disguise the appearance of the device by coloring the plastic or covering it up. It doesn’t have to be a terribly visible thing.”